Provider Demographics
NPI:1285300673
Name:RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Entity type:Organization
Organization Name:RIO GRANDE FOOT & ANKLE SPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEITHLOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-643-2921
Mailing Address - Street 1:2561 S 1560 W STE B
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-2361
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:
Practice Address - Street 1:404 BRUNN SCHOOL RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1102
Practice Address - Country:US
Practice Address - Phone:505-395-9575
Practice Address - Fax:877-540-1253
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIO GRANDE FOOT & ANKLE SPECIALISTS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-17
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty